Search

The prognostic value of BP elevation in very old patients with other chronic comorbidities is uncertain. We aimed to assess the prognostic impact of 24-hour BP (both brachial and central), BP variability, and pulse wave velocity (PWV) in very elderly patients hospitalized due to a chronic disease decompensation. We included 249 patients older than 80 years, admitted to the hospital due to decompensation of congestive heart failure (149), chronic obstructive pulmonary disease (60), chronic kidney disease with acute kidney injury (26), or other decompensated chronic conditions (14). During hospital stay, 24-h BP monitoring was performed (Mobil-O-Graph PWV). Mean values of brachial and central BP, aortic PWV, and BP variability (24-hour SD) were obtained in all participants. After discharge, patients were followed-up for one year. The primary outcome was total mortality. Hazard ratio (HR) of BP estimates (for 1 SD increase) were obtained through Cox models, adjusted for clinical confounders. During follow-up 72 patients (29%) died. Progression of heart failure (58%) was the most frequent cause of death. No differences were observed in 24-h BP between those who died or remained alive. Systolic BP-SD, and PWV were higher in patients who subsequently died, while 24-hour HR- SD was lower (Table). In fully adjusted models, PWV (HR: 3.54; 95%CI: 2.37-5.28), SD of 24-h brachial systolic BP (1.29; 1.00-1.67) and SD of 24-h heart rate (0.65; 0.46-0.91) were associated with the risk of mortality. We conclude that PWV, SBP and heart rate variabilities, but not the level of BP are associated with mortality in very old patients with advanced chronic conditions

Aims The objective of this study was to examine the validity of 1 h automated office blood pressure measurement for the diagnosis of hypertension. Methods We included patients requiring a hypertension diagnostic test. Participants underwent ambulatory blood pressure monitoring, 1 h automated office blood pressure measurement, office blood pressure measurement and home blood pressure monitoring. The prevalence of hypertension and subtypes were calculated. Mean values of ambulatory blood pressure monitoring were compared with 1 h automated office blood pressure measurement using the correlation coefficient and Bland-Altman graphs. The Kappa concordance index, sensitivity, specificity and diagnostic accuracy were calculated, and the area under the receiver operating characteristic curve was used to establish the diagnostic threshold of the 1-h measurement. Results Of 562 participants, 438 (87.6%) completed the four diagnostic methods. The 1-h method had a sensitivity of 76.6 [95% confidence interval (95% CI): 71.1-81.5], a specificity of 64.8% (95% CI: 57-72.1) and the best diagnostic accuracy (72.1%, 95% CI: 67.7-76.3) compared with the office and home measurements. Moderate-high correlations were observed between DBP (r = 0.73) and SBP (r = 0.58) readings. The 1-h method classified more patients as normotensive (24.4%) and fewer patients with white-coat hypertension (13.3%). A diagnostic threshold of at least 133/83 mmHg for the 1-h method could improve diagnostic accuracy by 2.3%. Conclusion One-hour automated blood pressure measurement is a valid, reliable method for the diagnosis of hypertension in undiagnosed patients. The diagnostic accuracy permits detection of white-coat and masked hypertension. To diagnose hypertension, the 1-h method or conventional home blood pressure monitoring should be used rather than office measurements. Trial registration ClinicalTrials.gov Identifier: NCT03147573.

The breakdown of vascular integrity triggers a series of reactions, initially involving a vasoconstriction phenomenon that reduces blood loss and leads to platelet plug formation under changing flow conditions. Once the platelet plug has formed, the coagulation system is activated in order to allow the formation of fibrin, which anchors the platelet plug to the vessel breach. Finally, once the damage has resolved, the fibrin is eliminated through fibrinolysis. This article explains all these regulatory mechanisms.

Obesity is a key factor for cardiovascular diseases and complications. Obesity is associated with hypertension, dyslipidemia and type II diabetes, which are the major predictors of cardiovascular disease in the future. It predisposes for atrial fibrillation, heart failure, sudden cardiac death, renal disease and ischemic stroke that are the main causes of cardiovascular hospitalization and mortality. As obesity and the cardiovascular effects on the vessels and the heart start early in life, even from childhood, it is important for health policies to prevent obesity very early before the disease manifestation emerge. Key roles in the prevention are strategies to increase physical exercise, reduce body weight and to prevent or treat hypertension, lipids disorders and diabetes earlier and efficiently to prevent cardiovascular complications.Epidemiology and mechanisms of obesity-induced hypertension, diabetes and dyslipidemia will be reviewed and the role of lifestyle modification and treatment strategies in obesity will be updated and analyzed. The best treatment options for people with obesity, hypertension, diabetes and dyslipidemia will discussed.

Peripheral BP variability (BPV) has been found to be increased in hypertensives with target organ damage (TOD). It is unknown if central BP variability follows the same pattern. We aimed to evaluate short-term BPV in a group of hypertensive subjects classified as having or not cardiac, renal, or vascular TOD. A total of 178 hypertensives (33% women; age 57±12) were evaluated. TOD was defined by the presence of left ventricular hypertrophy (LVH) on echocardiography, renal alterations (urinary albumin excretion >30mg/g or eGFR < 60 ml/min/1.73m 2 ) or aortic stiffness (aortic pulse wave velocity > 10 m/s). BPV was estimated by 24-hour peripheral and central BP monitoring. Parameters evaluated included: night-to-day ratios (NDR), standard deviation (SD) and coefficient of variation (CV) for 24 hours, day and night, weighted standard deviation (WSD) and average real variability (ARV). Ninety-two patients (51.7%) had TOD, distributed as follows: 66 (37.1%) had LVH, 47 (26.4%) had renal alterations, and 37 (20.8%) increased aortic stiffness. Systolic and diastolic night-to-day ratios and systolic BPV were increased in patients with TOD with respect to those without (table). No differences were observed in diastolic BPV. The increase in systolic BPV was also observed when comparing groups with or without LVH, renal damage or aortic stiffness. Brachial BPV exhibited the same increased variability as central BPV. We conclude that the presence of hypertensive cardiac, renal or vascular organ damage is associated with increased systolic central BPV and reduced systolic and diastolic nocturnal fall in BP. Central BPV follows the same pattern as observed with peripheral BPV.

To evaluate ambulatory blood pressure monitoring (ABPM) parameters in a broad sample of high-risk hypertensive patients.The Spanish Society of Hypertension is developing a nationwide project in which more than 900 physicians send ABPM registries and corresponding clinical records to a central database via www.cardiorisc.com. Between June 2004 and July 2005 a 20 000-patient database was obtained; 17 219 were valid for analysis.We identified 6534 patients with high cardiovascular risk according to the 2003 European Society of Hypertension/European Society of Cardiology guidelines stratification score. Office blood pressure (BP) was 158.8/89.9 mmHg and 24-h BP was 135.8/77.0 mmHg. Patients with grade 3 BP in the office showed ambulatory systolic BP values less than 160 mmHg in more than 80%. A non-dipping pattern was observed in 3836 cases (58.7%), whereas this abnormality was present in 47.9% of patients with low-to-moderate risk [odds ratio (OR) 1.54; 95% confidence interval (CI) 1.45-1.64]. The prevalence of non-dippers was higher as ambulatory BP increased ( approximately 70% when 24-h systolic BP155 mmHg) and was similar in both groups. At the lowest levels of BP (24-h systolic BP135 mmHg) a non-dipping pattern was more prevalent in high-risk cases (56.6 versus 45.7%; OR 1.51; 95% CI 1.40-1.64).There was a remarkable discrepancy between office and ambulatory BP in high-risk hypertensive patients. The prevalence of a non-dipper BP pattern was almost 60%. In the lowest levels of ambulatory BP, high-risk patients showed a higher prevalence of non-dipping BP than lower-risk cases. These observations support the recommendation of a wider use of ABPM in high-risk hypertensive patients.

PURPOSE OF REVIEW To review the antihypertensive, cardiovascular and pleiotropic effects of angiotensin-receptor blockers (ARBs). RECENT FINDINGS ARBs are the most recently approved class of antihypertensive agents. They selectively block the angiotensin II type 1 receptor, thus inhibiting most of the deleterious effects of angiotensin II. In addition to blood-pressure control, other benefits may be gained using ARBs. This is because the renin-angiotensin system plays a crucial role in circulatory homoeostasis, and in patients with atherosclerosis, diabetes or hypertension, angiotensin II contributes to the pathophysiology of disease. Evidence-based medicine includes well-controlled studies with mortality and morbidity endpoints in patients with a variety of conditions including hypertension, type 2 diabetes, stroke, renal disease, heart failure, left-ventricular hypertrophy and coronary heart diseases. In addition to these hard endpoints, it has been shown that treatment with ARBs prevents the development of type 2 diabetes, ameliorates coronary and peripheral vascular endothelial dysfunction and decreases plasma levels of several markers of vascular inflammation. SUMMARY ARBs are first-line agents for the treatment of hypertension and cardiovascular diseases. Blocking the renin-angiotensin system with these agents has special advantages due to specific vascular and antiatherosclerotic effects, which contribute to a better cardiovascular and renal protection in patients at risk from or with cardiovascular disease.

It has been reported that both the DD genotype of the angiotensin converting enzyme (ACE) gene and the presence of cerebral white matter lesions (WML) may represent risk factors for the development of stroke. The present study investigates a possible association between 3 different genetic polymorphisms of the renin-angiotensin system and the presence of WML in 60 never-treated essential hypertensive patients (36 men, 24 women), aged 50 to 60 years, without clinical evidence of target organ damage. All patients underwent brain magnetic resonance imaging to establish the presence or absence of WML. The insertion/deletion (I/D) ACE gene, the M235T angiotensinogen (AGT) gene, and the A1166C angiotensin II type 1 receptor gene polymorphisms were determined by standard polymerase chain reaction. Twenty-five hypertensive patients (41.6%) were found to have WML on brain magnetic resonance imaging. No significant association between the M235T angiotensinogen or A1166C angiotensin II type 1 receptor genotypes and the presence of WML was found. However, the frequency of the DD genotype in patients with WML (64%) was significantly higher than that observed in patients without WML (28.6%; P =0.022). The DD genotype odds ratio for the presence of WML was 4.44 (95% confidence interval: 1.48 to 13.3). Likewise, the proportion of the D allele in patients with WML (74%) was significantly higher ( P =0.014) than that observed in patients without WML (51.4%). We conclude that the presence of the DD genotype and/or the D allele of the ACE gene may be a predisposing factor for developing WML in essential hypertensive patients. However, because of the small sample size, these results require confirmation in a larger study.

Background Recent studies have raised concern about the safety of erythropoiesis‐stimulating agents because of evidence of increased risk of hypertension and cardiovascular morbidity and mortality in chronic kidney disease ( CKD ) patients. In the present study, we investigated the effects of recombinant human erythropoietin ( EPO ) on endothelial function of gluteal subcutaneous resistance arteries isolated from 17 stage 4 patients (estimated glomerular filtration rate 21.9±7.4 mL/min per 1.73 m 2 ) aged 63±13 years. Methods and Results Arteries were mounted on a pressurized myograph. EPO impaired endothelium‐dependent relaxation in a concentration‐dependent manner. The maximal response to acetylcholine with EPO at 1, 10, and 20 IU/mL was reduced by 12%, 34%, and 43%, respectively, compared with the absence of EPO ( P EPO ‐induced endothelial dysfunction was significantly associated with carotid stiffness and history of cardiovascular events. EPO had no effect on norepinephrine‐induced vasoconstriction or sodium nitroprusside–induced relaxation. ABT ‐627, an endothelin type A receptor antagonist, and tempol, a superoxide dismutase mimetic, partially reversed the altered endothelial function in the presence of EPO ( P EPO . Conclusions EPO alters endothelial function of resistance arteries in CKD patients via a mechanism involving in part oxidative stress and signaling through an endothelin type A receptor. EPO ‐induced endothelial dysfunction could contribute to deleterious effects of EPO described in large interventional trials.

Renal function and albuminuria predict CV disease in general population, but their predictive value in resistant hypertension (RH) is rather unknown. Aim: to determine the ability of renal parameters to predict adverse CV outcomes in RH patients. Methods: One hundred thirty-three (59% males, aged 61yr) RH pts. (BP ≥140/90 mmHg despite treated with ≥3 antihypertensive drugs) were evaluated. Mean follow-up: 88±5 months. Primary composite end-point: first occurrence of a CV event (nonfatal myocardial infarction, nonfatal stroke, new-onset heart failure, coronary or peripheral by-pass) or CV death. Renal function was assessed by serum creatinine, creatinine clearance (CrCL) and urine albumin/creatinine ratio (UACR). Microalbuminuria (MAB) was defined as UACR >30mg/g. Results: Twenty-two subjects (16.5%) reached the primary end-point. After adjustments for previous CV disease, systolic BP both at baseline and during follow-up and CrCl, high UACR during follow-up was significantly associated with a worse CV outcome (Table). More patients who had a CV event developed MAB at follow-up (28% vs. 6%), whereas the proportion with MAB regression in this group was lower (11% vs. 19%); p=0.005. Although renal function was also associated with outcome in unadjusted analyses, the significance was lost after baseline risk and BP adjustment. Conclusion: in patients with resistant hypertension, microalbuminuria at follow-up but not at baseline independently predicts CV outcomes. * adjusted for SBP both at baseline and during follow-up and previous CV disease ** adjusted for the aforementioned confounders plus CrCl both at baseline and at follow-up; UACR tested after log transformation.